Sustainable development in general practice.

BACKGROUND: As health care accounts for 4-5% of global carbon emissions, many health organisations have called for implementing sustainable development actions in health care. However, sustainable development measures in general practice are rarely implemented by physicians. The aim of this study was to explore the practices of general practitioners (GPs) in terms of sustainable development to identify which actions are appropriate and achievable. METHODS: A qualitative study was conducted in 12 French GPs using face-to-face or telephone interviews, transcribed verbatim and analysed through a global inductive analysis with constant comparison. Semi-structured interviews were focussed on waste management, relationships between health professionals, sustainable development, and GPs' activity. RESULTS: The mean age of the GPs was 42.8 years and they mainly worked in an urban environment. The interviews highlighted 4 themes. It appeared that a balance needs to be found between the environmental impact and the constraints related to medical care. To be able to think about integrating sustainable development into health care, GPs should make a personal commitment to change their routine. In practice, consumption should be reassessed, prescriptions and prevention reconsidered. These actions could be applied to the GPs' environment as role models for their patients, business leaders, and members of the healthcare system. CONCLUSION: GPs felt concerned by sustainable development and were already involved in its implementation in their practice. Tools are available to help GPs to continue to implement their actions described in this article, but their impact remains to be investigated.

In an era where global health is an increasing concern for the population, it appeared necessary to study the extent to which health professionals were willing to change their behaviours in their professional lives. This study was based on the interview of 12 French general practitioners and investigated their perspective on sustainable development and how they implemented it in their practice. Four main themes were highlighted. Some physicians did not spontaneously see the link between their practice and sustainable development. Our study showed that they were willing to adapt their practice despite organisational constraints and the difficulty in changing their behaviour.

Worker heat stress prevention and work metabolism estimation: comparing two assessment methods of the heart rate thermal component.

The heart rate thermal component ( ΔHRT ) can increase with body heat accumulation and lead to work metabolism (WM) overestimation. We used two methods (VOGT and KAMP) to assess ΔHRT of 35 forest workers throughout their work shifts, then compared ΔHRT at work and at rest using limits of agreement (LoA). Next, for a subsample of 20 forest workers, we produced corrected WM estimates from ΔHRT and compared them to measured WM. Although both methods produced significantly different ΔHRT time-related profiles, they yielded comparable average thermal cardiac reactivity (VOGT: 24.8 bpm °C-1; KAMP: 24.5 bpm °C-1), average ΔHRT (LoA: 0.7 ± 11.2 bpm) and average WM estimates (LoA: 0.2 ± 3.4 ml O2 kg-1min-1 for VOGT, and 0.0 ± 5.4 ml O2 kg-1min-1 for KAMP). Both methods are suitable to assess heat stress through ΔHRT and improve WM estimation. Practitioner summary: We compared two methods for assessing the heart rate thermal component ( ΔHRT ), which is needed to produce a corrected HR profile for estimating work metabolism (WM). Both methods yielded similar ΔHRT estimates that allowed accurate estimations of heat stress and WM at the group level, but they were imprecise at the individual level. Abbreviations: AIC: akaike information criterion; bpm: beats per minute; CI: confidence intervals; CV: coefficient of variation in %; CV drift: cardiovascular drift; ΔHRT: the heart rate thermal component in bpm; ΔHRT: the heart rate thermal component in bpm; ΔΔHRT: variation in the heart rate thermal component in bpm; ΔTC: variation in core body temperature in °C; HR: heart rate in bpm; HRmax: maximal heart rate in bpm; Icl: cloting insulation in clo; KAMP: Kampmann et al. (2001) method to determe ΔHRT; LoA: Limits of Agreement; PMV-PPD: the Predicted Mean Vote and Predicted Percentage Dissatisfied; PHS: Predicted Heat Strain model; RCM: random coefficients model; SD: standard deviation; TC: core body temperature in °C; TCR: thermal cardiac reactivity in bpm °C-1; τΔHRT: rate of change in the heart rate thermal component in bpm min-1; τTC: rate of change in core body temperature in °C min-1; tα,n-1: Student's t statistic with level of confidence alpha and n-1 degrees of freedom; TWL: Thermal Work Limit model; V̇O2 : oxygen consumption in ml O2 kg-1 min-1; V̇O2 max: maximal oxygen consumption in ml O2 kg-1 min-1; VOGT: Vogt et al. (1973) method to determine ΔHRT; WBGT: Wet-Bulb Globe Temperature in °C; WM: work metabolism.

Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey.

OBJECTIVES: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries. DESIGN: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making. SETTING: A primary care study; 25 participating centres in 20 European countries. PARTICIPANTS: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%. OUTCOME MEASURES: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons. RESULTS: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses. CONCLUSIONS: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

Assessment of quality of life, satisfaction with anticoagulation therapy, and adherence to treatment in patients receiving long-course vitamin K antagonists or direct oral anticoagulants for venous thromboembolism.

INTRODUCTION: Direct oral anticoagulants (DOACs) have shown non-inferiority and ease of use compared to vitamin K antagonists (VKA) in the treatment of venous thromboembolism (VTE). No study so far has been directed toward real-life experience of outpatients receiving anticoagulants for VTE in France. METHODS: This is an observational descriptive real-life epidemiological study, using three validated questionnaires (Morisky Medication Adherence Scale-8, EQ-5D, and part 2 of the Perception of Anticoagulant Treatment Questionnaire), to assess adherence, quality of life, and satisfaction in 100 VTE outpatients receiving anticoagulation therapy by VKA (primary or switched from DOAC to VKA) or by DOAC (primary or switched from VKA to DOAC). RESULTS: Patients were very much satisfied with their treatment in both DOAC and VKA groups. Despite advantages of DOACs, therapeutic adherence was only moderate. The best adherence scores were observed in the primary VKA switched to DOAC for at least 3 months (S-DOAC) subgroup. Quality of life was better in the DOAC group mainly because of the absence of the requirement for blood testing. Most of the complaints concerned the pain/discomfort dimension in the VKA group and anxiety/depression dimension in the DOAC group. CONCLUSION: Patients were satisfied with their anticoagulant treatment, especially when they were involved in choosing the anticoagulant, and the treatment suited them. Quality of life of patients in the DOAC group was better than in the VKA group, but adherence remains to be improved. This study highlights the importance of the physician-patient relationship, pretreatment initiation, and follow-up of any anticoagulation therapy throughout.

Private or salaried practice: how do young general practitioners make their career choice? A qualitative study.

BACKGROUND: Young French postgraduates in general practice increasingly prefer salaried practice to private practice in spite of the financial incentives offered by the French government or local communities to encourage the latter. This study aimed to explore the determinants of choice between private or salaried practice among young general practitioners. METHODS: A qualitative study was conducted in the South West of France. Semi-structured interviews of young general practitioners were audio-recorded until data saturation. Recordings were transcribed and then analyzed according to Grounded Theory by three researchers working independently. RESULTS: Sixteen general practitioners participated in this study. For salaried and private doctors, the main factors governing their choice were occupational factors: working conditions, need of varied scope of practice, quality of the doctor-patient relationship or career flexibility. Other factors such as postgraduate training, having worked as a locum or self-interest were also determining. Young general practitioners all expected a work-life balance. The fee-for-service scheme or home visits may have discouraged young general practitioners from choosing private practice. CONCLUSIONS: National health policies should increase the attractiveness of ambulatory general practice by promoting the diversification of modes of remuneration and encouraging the organization of group exercises in multidisciplinary medical homes and community health centers.